Smith, Donald 1
NEW YORK STATE DEPARTMENT OF HEALTH 1-1
Vital Records Section Burial - Transit Permit
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Name First '" Middle Last Sex
Donald William Smith Male
Date of Death Age If Veteran of U.S. Armed Forces,
01 /03/201 5 90 yrs. War or Dates 1 944-1 946
1- Place of Death Town of Hospital, Institution or
WCity, Town or Village Ticonderoga Street Address 11 Putts Pond Road
W Manner of Death Natural Cause El Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
O Nuzhat Syed M.D.
Address
7426 NYS Rt. 9N, Westport, NY 12993
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoq' 1 564 2
['Burial Date Cemetery or Crematory
❑Entombment 1 /7/201 5 Pine View Crematory
Address
Cremation Queensbury, New York
Date Place Removed
Zn Removal and/or Held
and/or Address
fl3
Hold
O Date Point of
d
ni
0 L jTransportation Shipment
O by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
11 Algonkin St. , Ticonderoga, NY 12883
Name of Funeral Firm Making Disposition or to Whom
1-= Remains are Shipped, If Other than Above
• Address
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LE!
` Permission is hereby granted to dispose of the human remains described above as indicated.
"> Date Issued 1 /6/2 01 5 Registrar of Vital Statistics ,i -?'( - l,1,6_1_,,,__,
t (signature)
District Number 1 564 Place Town of Ticonderoga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1
lU• Date of Disposition (/g f is flu Place of Disposition U,;,, L i06-.�
(address)
t:
CO
CC (section) (lot-number)` (grave number)
Name of Sexton or Person in Char a of Premises A
`' 1. J
Jrz / (pease print)
iti Signature "Lr Title CITE vlifiV2
(over)
DOH-1555 (02/2004)